Free Vastus Lateralis Muscle and Musculocutaneous Flaps: a Versatile Alternative to other Musculocutaneous or Muscle Flaps in Complex and Complicated Defects

Introduction: Anterolateral thigh perforator flap is a popular flap as well as workhorse in microsurgery. The aim of perforator flaps is to preserve the muscle and thus the function. However, in some situations muscle flaps may still be necessary. Vastus lateralis muscle or musculocutaenous flap can be good alternative to more classic muscle free flaps (latissimus dorsi, rectus abdominis, gracilis).

Methodology and Material: In a series of 69 consecutive patients of a single surgeon (9-88 years, 45M, 24F) free VL musculocutaneous or muscle flaps were utilized for head and neck (53), and lower extremity reconstructions (16). The specific indications were history of osteomyelitis in the lower extremity, large cavities, defects requiring bulk, intense irradiation, defects of the floor of the mouth and neck with exposed arteries, esophagus, bone and dura, and complex 3D defects of the craniofacial skeleton. The size of the skin paddle and/or muscle component of the flap was determined according to the requirements of the defect. When a segmental muscle was harvested the motor nerves to the remaining muscle were protected. Some flaps where elevated as chimeric flaps (17).

Results: One flap was lost (1.4%) due to undiagnosed hereditary coagulopathy syndrome. Two flaps to the lower extremity had venous thrombosis and were salvaged with vein grafts. Other less common complications that did not change the outcome were flap hematoma, recurrent osteomyelitis, hematoma of the donor area and wound dehiscence. Overall the flaps provided adequate healing to the structures being treated.

Conclusions: VL free flap can be a versatile alternative to other musculocutaneous or muscle flaps in complex and complicated defects. In patients with lower extremity reconstruction it preserves the upper extremity (latissimus dorsi) and abdominal musculature (rectus abdominis) for mobilization and transfer. In the head and neck reconstruction it enables two team approach. The long pedicle is ideal to reach outside the zone of injury or cross the neck when recipients’ vessels are in paucity. It provides a safer alternative to tedious perforator dissection and incorporates multiple perforators. The donor area complications are minimal and well tolerated by the patient.